: University of Denver HMO 225
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 07/01/2015 - 06/30/2016
Coverage for: Individual / Family | Plan Type: HMO
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan
document at www.kp.org or by calling 1-855-249-5005 or TTY 1-800-521-4874.
Important Questions
What is the overall
deductible?
Are there other
deductibles for specific
services?
Answers
Why this Matters:
$0
See the chart starting on page 2 for your costs for services this plan covers.
No
You don’t have to meet deductibles for specific services, but see the chart starting on page
2 for other costs for services this plan covers.
Is there an out–of–
pocket limit on my
expenses?
Yes, $2,000 individual / $4,500
family
What is not included in
the out–of–pocket
limit?
Premiums, balanced-billed
charges and health care this plan
doesn’t cover; (certain other
Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
services may not apply to the
out-of-pocket maximum)
Is there an overall
annual limit on what
the plan pays?
No
The chart starting on page 2 describes any limits on what the plan will pay for specific
covered services, such as office visits.
Does this plan use a
network of providers?
Yes, see www.kp.org or call 1855-249-5005 (TTY 1-800-5214874) for a list of plan
providers.
If you use an in-network doctor or other health care provider, this plan will pay some or all
of the costs of covered services. Be aware, your in-network doctor or hospital may use an
out-of-network provider for some services. Plans use the term in-network, preferred, or
participating for providers in their network. See the chart starting on page 2 for how this
plan pays different kinds of providers.
No
You can see the specialist you choose without permission from this plan.
Yes
Some of the services this plan doesn’t cover are listed on page 5. See your policy or plan
document for additional information about excluded services.
Do I need a referral to
see a specialist?
Are there services this
plan doesn’t cover?
The out-of-pocket limit is the most you could pay during a coverage period (usually one
year) for your share of the cost of covered services. This limit helps you plan for health
care expenses.
Questions: Call 1-855-249-5005 (TTY 1-800-521-4874) or visit us at www.kp.org. If you aren’t clear about any of the bolded terms used in this form, see
the Glossary. You can view the Glossary at www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call 1-855-249-5005 (TTY 1-800-521-4874) to request a
copy.
Page 1 of 8
• Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
• Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if
the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if
you haven’t met your deductible.
• The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the
allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and
the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
• This plan may encourage you to use plan providers by charging you lower deductibles, copayments and coinsurance amounts.
Common
Medical Event
Services You May
Need
Primary care visit to treat
an injury or illness
Specialist visit
If you visit a health
care provider’s office
or clinic
If you have a test
Other practitioner office
visit
Preventive care/
screening/immunization
Diagnostic test (x-ray,
blood work)
Imaging (CT/PET scans,
MRIs)
Your Cost If
You Use a NonPlan Provider
Limitations & Exceptions
$25 per visit
Not covered
---none---
$40 per visit
Not covered
Spinal manipulations: $20 per visit;
Acupuncture services: Not covered
Not covered
---none--Other practitioners are defined as spinal
manipulations and acupuncture services.
Does not apply to the out-of-pocket
maximum; coverage is limited to 20
visits per year for spinal manipulations.
No charge
Not covered
---none---
X-ray: No charge Lab: No charge
Not covered
---none---
$100 per test
Not covered
Multiple cost shares may apply per
encounter.
Your Cost If You Use a Plan
Provider
Page 2 of 8
Common
Medical Event
If you need drugs to
treat your illness or
condition
More information
about prescription
drug coverage is
available at
www.kp.org/formulary
If you have
outpatient surgery
If you need
immediate medical
attention
If you have a hospital
stay
Services You May
Need
Your Cost If You Use a Plan
Provider
Your Cost If
You Use a NonPlan Provider
Limitations & Exceptions
Generic drugs
$15/retail prescription; $30/mail
order prescription
Not covered
Brand drugs
$25 /retail prescription; $50/mail
order prescription
Not covered
Non-preferred drugs
Not covered
Not covered
Specialty drugs
Cost share for generic, brand or nonNot covered
preferred drugs may apply
Subject to formulary guidelines.
Infertility drugs not covered. Federally
mandated over the counter items are
covered with a prescription when filled
at a Kaiser Permanente pharmacy.
Subject to formulary guidelines.
Infertility drugs not covered.
Except those prescribed and authorized
through the non-preferred drug process
(subject to the brand copay); infertility
drugs not covered.
Subject to formulary guidelines.
Infertility drugs not covered.
Facility fee (e.g.,
ambulatory surgery center)
$100 per surgery
Not covered
---none---
Included in facility fee (see facility
fee under "If you have outpatient
surgery")
Not covered
---none--Does not include imaging (CT/PET
scans, MRIs); The “Emergency room
services” and “Imaging (CT/PET scans,
MRIs)” copayment, if applicable, are
waived if you are admitted directly to the
hospital as an inpatient.
Physician/surgeon fees
Emergency room services
$100 per visit
$100 per visit
Emergency medical
transportation
20% coinsurance up to $500 per trip
20% coinsurance
up to $500 per trip
Urgent care
$50 per visit
$50 per visit
Non-Plan Providers: only covered if you
are out of the service area.
Facility fee (e.g., hospital
room)
$500 per admission
Not covered
---none---
See Facility fee under "If you have a
hospital stay"
Not covered
---none---
Physician/surgeon fee
---none---
Page 3 of 8
Your Cost If
You Use a NonPlan Provider
Limitations & Exceptions
$25 per visit; group visits are 50% of
the individual visit
Not covered
---none---
$500 per admission
Not covered
---none---
$25 per visit; group visits are 50% of
Not covered
the individual visit
---none---
$500 per admission
Not covered
---none---
Prenatal and postnatal care
No charge
Not covered
Delivery and all inpatient
services
After confirmation of pregnancy, for the
normal series of regularly scheduled
routine visits.
$500 per admission
Not covered
---none---
Home health care
No charge
Not covered
Rehabilitation services
$25 per visit for outpatient services;
See Facility fee under "If you have a
hospital stay" for inpatient services.
Not covered
Habilitation services
Not covered
Not covered
Coverage is limited to less than 8 hours
per day and 28 hours per week
Outpatient visits limited to 20 visits per
therapy per year (autism spectrum
disorders are not subject to the visit
limit); Inpatient in a multi-disciplinary
facility limited to 60 days per condition
per year.
---none---
Skilled nursing care
No charge
Not covered
Coverage is limited to 100 days per year
Durable medical
equipment
20% coinsurance
Not covered
No charge
$25 per visit for routine refractive
exam
Not covered
Not covered
Not covered
Common
Medical Event
Services You May
Need
If you have mental
health, behavioral
health, or substance
abuse needs
Mental/Behavioral health
outpatient services
Mental/Behavioral health
inpatient services
Substance use disorder
outpatient services
Substance use disorder
inpatient services
If you are pregnant
If you need help
recovering or have
other special health
needs
Hospice service
If your child needs
dental or eye care
Eye exam
Glasses
Dental check-up
Your Cost If You Use a Plan
Provider
Not covered
Not covered
Not covered
Coverage is limited to items on our
DME formulary. Prosthetic arms and
legs not to exceed 20% coinsurance.
---none--For services with an ophthalmologist see
“Specialist visit”
---none-----none--Page 4 of 8
Excluded Services & Other Covered Services:
Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)
•
•
Non-emergency care when traveling outside
the U.S.
Habilitation services
•
Routine foot care
Hearing Aids (Adult)
•
Weight loss programs
•
Glasses
•
•
•
•
Acupuncture
•
Cosmetic surgery
•
•
Dental care (Adult)
•
Long-term care
Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these
services.)
•
•
Hearing Aids (Children under the age of 18)
•
Bariatric surgery
•
Infertility treatment
•
Spinal manipulations
•
Private duty nursing
•
Routine eye care (Adult)
Your Rights to Continue Coverage:
If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that
allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be
significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may
also apply.
For more information on your rights to continue coverage, contact the plan at 1-855-249-5005 or TTY 1-800-521-4874. You may also
contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272
or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.
Page 5 of 8
Your Grievance and Appeals Rights:
If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a
grievance. For questions about your rights, this notice, or assistance, you can contact: The plan at 1-855-249-5005 or TTY 1-800-5214874; Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform; or
the Colorado Division of Insurance, Consumer Affairs Section, at 1560 Broadway, Ste 850, Denver, CO 80202 or call: 303-894-7490
(in-state, toll-free: 800-930-3745), or email: [email protected].
Does this Coverage Provide Minimum Essential Coverage?
The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This
plan or policy does provide minimum essential coverage.
Does this Coverage Meet the Minimum Value Standard?
The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60%
(actuarial value). This health coverage does meet the minimum value standard for the benefits it provides.
Language Access Services:
SPANISH (Español): Para obtener asistencia en Español, llame al 1-855-249-5005 or TTY/TDD Colorado Springs: 1-800-521-4874 Denver/Boulder:
1- 303-338-3820
TAGALOG (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-855-249-5005 or TTY/TDD Colorado Springs: 1-800-521-4874
Denver/Boulder: 1-303-338-3820
CHINESE: 若有問題：請撥打1-855-249-5005 或 TTY/TDD Colorado Springs: 1-800-521-4874 Denver/Boulder: 1-303-338-3820
NAVAJO (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-855-249-5005 or TTY/TDD Colorado Springs: 1-800-521-4874
Denver/Boulder: 1-303-338-3820.
––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––
Page 6 of 8
: University of Denver HMO 225
Coverage Examples
About these Coverage
Examples:
These examples show how this plan might cover
medical care in given situations. Use these
examples to see, in general, how much financial
protection a sample patient might get if they are
covered under different plans.
This is
not a cost
estimator.
Don’t use these examples to
estimate your actual costs
under this plan. The actual
care you receive will be
different from these
examples, and the cost of
that care will also be
different.
See the next page for
important information about
these examples.
Coverage Period: 07/01/2015 - 06/30/2016
Coverage for: Individual / Family | Plan Type: HMO
Having a baby

Managing type 2 diabetes
(normal delivery)
(routine maintenance of
a well-controlled condition)

Amount owed to providers: $5,400
 Plan pays $4,120
 Patient pays $1,280
Amount owed to providers: $7,540
 Plan pays $6,840
 Patient pays $700
Sample care costs:
Hospital charges (mother)
Routine obstetric care
Hospital charges (baby)
Anesthesia
Laboratory tests
Prescriptions
Radiology
Vaccines, other preventive
Total
Patient pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total
$2,700
$2,100
$900
$900
$500
$200
$200
$40
$7,540
$0
$500
$0
$200
$700
Sample care costs:
Prescriptions
Medical Equipment and Supplies
Office Visits and Procedures
Education
Laboratory tests
Vaccines, other preventive
Total
$2,900
$1,300
$700
$300
$100
$100
$5,400
Patient pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total
$0
$900
$300
$80
$1,280
Total amounts above are based on subscriber only coverage.
Page 7 of 8
: University of Denver HMO 225
Coverage Examples
Coverage Period: 07/01/2015 - 06/30/2016
Coverage for: Individual / Family | Plan Type: HMO
Questions and answers about the Coverage Examples:
What are some of the
assumptions behind the
Coverage Examples?
•
•
•
•
•
•
•
Costs don’t include premiums.
Sample care costs are based on national
averages supplied by the U.S.
Department of Health and Human
Services, and aren’t specific to a
particular geographic area or health plan.
The patient’s condition was not an
excluded or preexisting condition.
All services and treatments started and
ended in the same coverage period.
There are no other medical expenses for
any member covered under this plan.
Out-of-pocket expenses are based only
on treating the condition in the example.
The patient received all care from innetwork providers. If the patient had
received care from out-of-network
providers, costs would have been higher.
What does a Coverage Example
show?
Can I use Coverage Examples
to compare plans?
For each treatment situation, the Coverage
Example helps you see how deductibles,
copayments, and coinsurance can add up. It
also helps you see what expenses might be left
up to you to pay because the service or
treatment isn’t covered or payment is limited.
Yes. When you look at the Summary of
Does the Coverage Example
predict my own care needs?
 No. Treatments shown are just examples.
The care you would receive for this
condition could be different based on your
doctor’s advice, your age, how serious your
condition is, and many other factors.
Does the Coverage Example
predict my future expenses?
No. Coverage Examples are not cost
estimators. You can’t use the examples to
estimate costs for an actual condition. They
are for comparative purposes only. Your
own costs will be different depending on
the care you receive, the prices your
providers charge, and the reimbursement
your health plan allows.
Benefits and Coverage for other plans,
you’ll find the same Coverage Examples.
When you compare plans, check the
“Patient Pays” box in each example. The
smaller that number, the more coverage
the plan provides.
Are there other costs I should
consider when comparing
plans?
Yes. An important cost is the premium
you pay. Generally, the lower your
premium, the more you’ll pay in out-ofpocket costs, such as copayments,
deductibles, and coinsurance. You
should also consider contributions to
accounts such as health savings accounts
(HSAs), flexible spending arrangements
(FSAs) or health reimbursement accounts
(HRAs) that help you pay out-of-pocket
expenses.
SBC #13364
Questions: Call 1-855-249-5005 (TTY 1-800-521-4874) or visit us at www.kp.org. If you aren’t clear about any of the bolded terms used in this form, see
the Glossary. You can view the Glossary at www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call 1-855-249-5005 (TTY 1-800-521-4874) to request a
copy.
Page 8 of 8